Provider Demographics
NPI:1336193119
Name:BRYAN C RUSSELL
Entity type:Organization
Organization Name:BRYAN C RUSSELL
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BRYAN
Authorized Official - Middle Name:C
Authorized Official - Last Name:RUSSELL
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:856-983-4499
Mailing Address - Street 1:651 ROUTE 73 N STE 304
Mailing Address - Street 2:
Mailing Address - City:MARLTON
Mailing Address - State:NJ
Mailing Address - Zip Code:08053-3446
Mailing Address - Country:US
Mailing Address - Phone:856-983-4499
Mailing Address - Fax:856-983-0435
Practice Address - Street 1:651 ROUTE 73 N STE 304
Practice Address - Street 2:
Practice Address - City:MARLTON
Practice Address - State:NJ
Practice Address - Zip Code:08053-3446
Practice Address - Country:US
Practice Address - Phone:856-983-4499
Practice Address - Fax:856-983-0435
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-19
Last Update Date:2023-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ1055389OtherCIGNA
NJ2035367OtherAETNA
NJ2153560OtherUNITED HEALTCARE
NJ0519113000OtherAMERIHEALTH/KEYSTONE
NJ2035367OtherAETNA